A 48-year-old male presents with 2 weeks of severe right lower quadrant abdominal pain and inguinal pain. The patient had similar pain 2 weeks ago, was referred to a surgery clinic, but was lost to follow up. The pain has been progressively worsening over the last 2 days. It’s now severe, associated with nausea and vomiting, does not radiate, and it is worsened with coughing and sneezing. He also endorses polyuria for an unknown length of time. His last bowel movement was 3 days ago. He denies diarrhea, constipation, hematochezia, melena, dysuria, hematuria, or recent trauma.
Vitals: Temp 97.7; HR 62; BP 129/84; RR 18; SpO2 99% on RA
General: Well appearing, in no acute distress, currently asking to eat food
Cardiovascular: Regular rate and rythum, no murmur
Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales or rhonchi
Abdominal: Soft, normal bowel sounds, with tenderness in the RLQ and the right groin. No rebound or guarding, no CVA tenderness, no abdominal or inguinal hernias palpated, and negative Rovsing’s sign
Genitourinary: Normal lay, circumcised, cremaster reflex intact, no testicular or epididymal tenderness, no masses, no rashes lesions or penile discharge
CBC: WBC 4.6 x 10^9/L; Hgb 11.6 g/dL; Hct 35.8%; Plt 172 x 10^9/L
BMP: Na 144 mmol/L; K 4.3 mmol/L; Cl 104 mmol/L; CO2 26.0 mmol/L; Glu 63 mg/dL; BUN 16 mg/dL; Cr. 0.82 mg/dL; Ca 9.5 mmol/L
LFT: AST 4.8 U/L; ALT 33 U/L; ALK 76 U/L
Lipase: 7 U/L
Appendicitis incarcerated into the right inguinal canal
The CT results demonstrated Amyand’s hernia, which occurs when the appendix herniates through the inguinal ring and becomes incarcerated. Amyand’s hernia makes up less than 1% of inguinal hernias; and of all cases of appendicitis, only 0.1% present as Amyand’s hernia.
Pathological examination of the appendix found dark red and hemorrhagic segments consistent with incarceration. Definitive management is surgical removal of the appendix, and surgical consultation was immediately sought.
Take Home Points
- In the context of abdominal and pelvic pain, appendicitis is always on the differential.
- Appendicitis doesn’t necessarily need to present acutely.